[Acute cytomegalovirus proctitis in a immunocompetent patient]

Cases of CMV proctitis are frequently reported in immunocompromised patients. However, some cases of CMV proctitis are linked to a CMV primary infection and to unprotected anal intercourse in immunocompetent patients. The most common symptom is bloody diarrhea (hemorrhagic colitis). The endoscopic exam can present in distincts forms. The diagnostic is based on a set of clinical, biological, endoscopic and histological arguments. The prognosis of the disease is favorable. The treatment is supportive. A research on other sexually transmitted diseases must be conducted.

Radiation induces proinflammatory dysbiosis: transmission of inflammatory susceptibility by host cytokine induction

OBJECTIVE

Radiation proctitis (RP) is a complication of pelvic radiotherapy which affects both the host and microbiota. Herein we assessed the radiation effect on microbiota and its relationship to tissue damage using a rectal radiation mouse model.

DESIGN

We evaluated luminal and mucosa-associated dysbiosis in irradiated and control mice at two postradiation time points and correlated it with clinical and immunological parameters. Epithelial cytokine response was evaluated using bacterial-epithelial co-cultures. Subsequently, germ-free (GF) mice were colonised with postradiation microbiota and controls and exposed to radiation, or dextran sulfate-sodium (DSS). Interleukin (IL)-1β correlated with tissue damage and was induced by dysbiosis. Therefore, we tested its direct role in radiation-induced damage by IL-1 receptor antagonist administration to irradiated mice.

RESULTS

A postradiation shift in microbiota was observed. A unique microbial signature correlated with histopathology. Increased colonic tumor necrosis factor (TNF)α, IL-1β and IL-6 expression was observed at two different time points. Adherent microbiota from RP differed from those in uninvolved segments and was associated with tissue damage. Using bacterial-epithelial co-cultures, postradiation microbiota enhanced IL-1β and TNFα expression compared with naïve microbiota. GF mice colonisation by irradiated microbiota versus controls predisposed mice to both radiation injury and DSS-induced colitis. IL-1 receptor antagonist administration ameliorated intestinal radiation injury.

CONCLUSIONS

The results demonstrate that rectal radiation induces dysbiosis, which transmits radiation and inflammatory susceptibility and provide evidence that microbial-induced radiation tissue damage is at least in part mediated by IL-1β. Environmental factors may affect the host via modifications of the microbiome and potentially allow for novel interventional approaches via its manipulation.

[IMMUNOHISTOCHEMICAL AND CYTOLOGICAL ASSESSMENT OF LOCAL INFLAMMATORY REACTION IN THE EARLY POSTOPERATIVE PERIOD IN PATIENTS UNDERGOING SURGERY FOR COMPLEX FORMS OF ACUTE PARAPROCTITIS]

The optimal time to fulfill the second (plastic) phase delayed early radical surgery in patients over the complicated forms of acute paraproctitis. On the 7th day after the opening of an abscess in a smear from the surface layer of the wound inflammatory regenerative cytogram type was observed in 66.8% of patients, early regenerative type--at 33.2%. On the 10th day was observed regenerative cytogram type. The dynamics of the concentration of cytokines in wound fluid on the 7th day showed a favorable course of wound healing process, without increasing the levels of proinflammatory cytokines, which allowed to perform the second stage of early delayed surgery in 7-10 days.

The efficacy of amino acid-based formulas in relieving the symptoms of cow's milk allergy: a systematic review

The aim of this systematic review was to evaluate the efficacy of amino acid-based formulas (AAF) in patients with cow's milk allergy (CMA). Studies were identified using electronic databases and bibliography searches. Subjects eligible for inclusion were patients of any age with CMA or symptoms suggestive of it. Comparisons of interest were AAF vs. extensively hydrolysed formula (eHF), AAF vs. soy-based formula (SF) and AAF vs. cow's milk or cow's milk-based formula. Outcomes of interest were gastrointestinal (GI), dermatological, respiratory and behavioural symptoms as well as growth. A total of 20 studies [three head-to-head randomized controlled trials (RCTs), three cross-over challenge RCTs, seven clinical trials (CTs) and seven case reports (CRs)] were included in the review. In infants with confirmed or suspected CMA, the use of an AAF was shown to be safe and efficacious. Findings from RCT comparisons of AAF with eHF showed that both formulas are equally efficacious at relieving the symptoms of CMA in confirmed or suspected cases. However, infants in specific subgroups (e.g. non-IgE mediated food-induced gastro-enterocolitis-proctitis syndromes with failure to thrive, severe atopic eczema, or with symptoms during exclusive breastfeeding) were more likely overall to benefit from AAF, as intolerance to eHF may occur. In such cases, symptoms persisting despite eHF feeding usually remit on AAF, and catch-up growth may be seen. Meta-analysis of the findings was not possible due to lack of homogenous reporting of outcomes in the original trials. This systematic review shows clinical benefit from use of AAF in both symptoms and growth in infants and children with CMA who fail to tolerate eHF. Further studies are required to determine the relative medical or economic value of initial treatment with AAF in infants at high risk of eHF intolerance.

Severe proctitis, perforation, and fatal rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor-Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.

Pit patterns in rectal mucosa assessed by magnifying colonoscope are predictive of relapse in patients with quiescent ulcerative colitis

BACKGROUND

Relapse of ulcerative colitis is difficult to predict by routine colonoscopy. A high-resolution video-magnifying colonoscope with chromoscopy enables the observation of colorectal mucosal pit patterns.

AIMS

To investigate the association of pit patterns as assessed by magnifying colonoscopy (MCS) with histological inflammation and mucosal chemokine activity in patients with quiescent ulcerative colitis, and to prospectively analyse the prognostic factors that may predict exacerbations.

METHODS

MCS was performed in 113 patients with ulcerative colitis in remission. Pit patterns in the rectal mucosa were classified into four MCS grades on the basis of size, shape and arrangement. Mucosal interleukin (IL) 8 activity was measured in biopsy specimens of rectal mucosa and the specimens were assessed for histological disease activity. The patients were then followed until relapse or for a maximum of 12 months. Multivariate survival analysis was carried out to determine the independent predictors of clinical relapse.

RESULTS

A positive correlation was identified between MCS grade, histological grade (p = 0.001) and mucosal IL8 activity (p<0.001). Multivariate proportional hazard model analysis showed that MCS grade was a significant predictor of relapse (relative risk 2.06, p = 0.001). Kaplan-Meier estimate of relapse during 12 months of follow-up was found to increase with increasing MCS grade, with values of 0% for grade 1, 21% for grade 2, 43% for grade 3 and 60% for grade 4.

CONCLUSION

MCS grading is associated with the degree of histological inflammation and mucosal IL8 activity in patients with quiescent ulcerative colitis, and may predict the probability of subsequent disease relapse in patients with ulcerative colitis in remission.

Circulating auto-antibody against hepatoma-derived growth factor (HDGF) in patients with ulcerative colitis

BACKGROUND/AIMS

Various circulating auto-antibodies have been reported in patients with ulcerative colitis. Hepatoma-derived growth factor (HDGF) is a mitogen, localized dominantly in the nucleus of proliferating cells. In this study, we demonstrated the circulating anti-HDGF auto-antibody and investigated its clinical roles in patients with ulcerative colitis.

METHODOLOGY

Anti-HDGF IgG antibodies were measured by the enzyme-linked immunosorbent assay with recombinant HDGF in 20 healthy volunteers and 40 patients with ulcerative colitis.

RESULTS

Circulating anti-HDGF antibody was detected in the serum of a patient with total colitis by Western blotting. Anti-HDGF auto-antibodies were detected at 65.6% in the serum of patients with total/left-sided colitis, compared with healthy subjects at 10%. During active stage, the circulating anti-HDGF auto-antibodies were detected at a higher frequency of 78.3% than those in remission stage at 37.5%. Furthermore, the titers during active colitis were higher than those during the remission stage. Anti-HDGF auto-antibodies were not detected in any patients with proctitis.

CONCLUSIONS

These findings suggest that anti-HDGF auto-antibodies in the serum of patients with ulcerative colitis would help to classify the total/left-sided colitis from proctitis, and the serial measurement of the titer would also be a good marker for the active colitis.

Neutrophil and eosinophil granule proteins as markers of response to local prednisolone treatment in distal ulcerative colitis and proctitis

OBJECTIVE

The pathophysiological role of neutrophil and eosinophil granulocytes in relation to steroid enema treatment was studied in patients with distal ulcerative colitis and proctitis.

METHODS

The rectal release of the neutrophil (myeloperoxidase, MPO), and eosinophil (eosinophilic cationic protein, ECP and eosinophil peroxidase, EPO) granule constituents were measured in 11 patients using intraluminal segmental perfusion of the rectum. The released amounts of MPO, ECP, and EPO in the perfusion fluids were determined by radioimmunoassays before and during prednisolone enema treatment and related to clinical, endoscopical, and histopathological data in addition to treatment outcome.

RESULTS

Clinical activity and particularly endoscopic activity correlated well with intraluminal MPO concentrations both before and during treatment. At the end of the study, eight of 11 patients fulfilled predefined response criteria; all responding patients had significant decrease of MPO concentrations (p < 0.01). This decline of MPO concentration was seen after 7 days of treatment (p < 0.05) in the response group and often occurred before clinical improvement. There was a nonsignificant trend toward a decrease in the concentrations of ECP and EPO at the end of treatment in responders.

Distal procto-colitis, natural cytotoxicity, and essential fatty acids

OBJECTIVES

Recently, it has been postulated that patients with ulcerative colitis have altered natural cytotoxicity, in particular natural killer (NK) and lymphokine-activated killer (LAK) cell activities. These cellular mechanisms have been postulated to play an etiological role in the pathogenesis of the disease process. We have shown previously that the essential fatty acids (EFA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) specifically inhibit natural cytotoxicity. Our aim was to evaluate the role of omega-3 EFA in the modulation of natural cytotoxicity and disease activity in patients with distal procto-colitis.

METHODS

In this pilot study patients were randomized into two groups. Each patient received either fish oil extract (EPA, 3.2 g, and DHA, 2.4 g) (n = 9) or sunflower oil (placebo) (n = 9) daily in a double-blind manner for 6 months. Monthly assessments of disease activity (clinical and sigmoidoscopic scores) and histological evaluation of mucosal biopsies were carried out. Also, the circulating levels and activities of NK and LAK cells, using flow cytometric analysis (CD16+ CD56+) and in vitro 51 chromium release assays (K562), respectively, were monitored.

RESULTS

After 6 months' supplementation with EFA, there was improvement in the clinical activity compared with pretreatment evaluation. There was significant reduction in the sigmoidoscopic and histological scores in the EFA group compared with the placebo group. Essential fatty acid supplementation for 6 months also induced significant reduction in the circulating numbers of CD16+ and CD56+ cells and the cytotoxic activity of NK cells, compared with the placebo group.

CONCLUSIONS

This pilot study has demonstrated that omega-3 fatty acids can suppress natural cytotoxicity and reduce disease activity in patients with distal procto-colitis. These findings suggest a therapeutic strategy for managing patients with inflammatory bowel disease.

Anti-neutrophil antibodies in inflammatory bowel disease: prevalence and diagnostic role

Anti-neutrophil antibodies have been shown in sera from patients with a variety of inflammatory diseases. Those reacting with components of neutrophil cytoplasm are associated with systemic vasculitis. Both nuclear and perinuclear staining patterns on human neutrophils have been reported using sera from patients with inflammatory bowel disease. We have evaluated the reactivity against human neutrophils of sera from 100 patients with inflammatory bowel disease, 14 disease controls, and 20 normal volunteers. Altogether 27/50 (54%) sera from patients with ulcerative colitis contained antibodies that reacted with cytospun ethanol fixed neutrophils compared with 5/50 (10%) from Crohn's disease (p less than 0.001) and 0/34 control sera (p less than 0.001). All seven sera from patients with proctitis alone were negative (p less than 0.01). There was no correlation between presence or titre of anti-neutrophil antibodies and either disease activity or treatment. Positive sera gave three different staining patterns on human neutrophils. The predominant pattern was perinuclear (17/32); 12 sera gave a cytoplasmic and three a homogeneous nuclear staining pattern. None of the patients or the controls had antibodies to myeloperoxidase, elastase, or serine proteinase 3, all of which are recognised by anti-neutrophil cytoplasmic antibodies. Only 2/27 sera positive by indirect immunofluorescence reacted with an extract of neutrophil primary granules. In conclusion, anti-neutrophil antibodies occur more commonly in ulcerative colitis than in Crohn's disease or control subjects and the anti-neutrophil antibodies found in inflammatory bowel disease are different from those associated with vasculitis.

Inflammatory cells in graft-versus-host disease on the rectum: immunopathologic analysis

The inflammatory infiltrate of acute rectal graft-versus-host disease (GVHD) was investigated by indirect immunofluorescence. Twenty biopsies from 11 allogeneic bone marrow transplant recipients were studied in four groups: biopsies before transplantation; biopsies after transplantation without GVHD; biopsies from patients with extra-intestinal GVHD only; and biopsies from patients with intestinal GVHD. Total T cell numbers (CD2+, CD3+) in the lamina propria differed little in the four groups. CD4+ lymphocytes appeared to be decreased in GVHD while CD8+ lymphocytes were significantly increased (p less than 0.01), thus significantly lowering the CD4/CD8 ratio. In pre-transplant patients and in those without GVHD this ratio resembled that in normal peripheral blood (1.44 +/- 0.5 and 2.46 +/- 1.3, respectively) but was significantly lower in both extraintestinal (0.71 +/- 0.08) and intestinal GVHD (0.56 +/- 0.08) (p less than 0.05). Acute intestinal GVHD was marked by a fourfold increase in CD57+ lymphoid cells within the epithelium and the lamina propria (p less than 0.05). The recognition of CD57+ cells, which may include natural killer-like cells, within rectal lymphoid infiltrates suggests a possible role for non-HLA restricted effector cells in GVHD of the rectum.

[Lysosomal-cation test in the control of treatment of acute proctological diseases]

An express evaluation of the functional state of neutrophil granulocytes by the indications of the lysosomal-cationic test are thought to be a necessary addition to routine clinico-laboratory methods of assessment of the wound process in patient with the suppurating epithelial coccygeal canal and acute paraproctitis. Use of cytochemical indices allow the antibacterial therapy to be optimized in patients with suppurating epithelial coccygeal canal and thus substantially decrease the amount of complications in the postoperative period.

Topical treatment of ulcerative proctitis with lidocaine

Rectal biopsy specimens from patients with ulcerative proctitis/proctosigmoiditis (UP/PS) were investigated immunocytochemically. In general, a changed mucosal innervation was demonstrated, with a marked increase in the number of nerve fibres and terminals with neuropeptide Y and tyrosine hydroxylase. In a few patients a hyperinnervation with VIPergic or SPergic nerves was seen. These findings indicate that hyperactive local nervous reflexes are of pathogenetic importance. To silence such activity, the diseased mucosa was treated with topically applied lidocaine. Such topical treatment with lidocaine gel in 21 consecutive patients with UP/PS for 3-8 weeks caused a rapid decrease of subjective and objective symptoms. During treatment mucosal integrity was restored, accompanied by depletion of OKT4 and OKT8 lymphocytes from the mucosa. However, the hyperinnervation pattern persisted during treatment.

Prevalence of sexually transmitted disease among male patients presenting with proctitis

Fifty male patients with proctitis were examined and the clinical, microbiological, serological and proctological features compared with 51 known male homosexuals attending the genitourinary (GU) clinic at the same hospital. The homosexuals had a short history of bowel symptoms, minor sigmoidoscopic and histological changes on rectal biopsy and many positive serological markers of sexually transmitted infection. There was some evidence of sexually transmitted disease in the IBD patients and three were homosexuals. IgG antibodies were positive for chlamydia trachomatis (n = 10) and hepatitis A (n = 7). One had a positive screening test for syphilis. Stool examination and rectal swab cultures were positive in two patients for cryptosporidium and cytomegalovirus respectively. Gastroenterologists must be aware of the possibility of specific infection in IBD patients and a clinical history should include sexual preferences and practices. If homosexuality is admitted, specific infection must be sought and excluded.

Mucosal T cells provide helper function but do not proliferate when stimulated by specific antigen in lymphogranuloma venereum proctitis in nonhuman primates

To study antigen-specific immune responses of gut-associated T lymphocytes after gastrointestinal infection, Cynomolgus monkeys were inoculated rectally with Chlamydia trachomatis of the L2 [lymphogranuloma venereum (LGV)] strain. Infected monkeys developed a chronic proctitis with the appearance of LGV-specific immunoglobulin G-antibodies in the serum. Lymphocytes isolated from the peripheral blood, the spleen, and draining lymph nodes had a vigorous antigen-specific proliferative response to LGV in vitro. Both T and B cells proliferated in response to stimulation with LGV, but B-cell proliferation was T-cell-dependent, as shown by cell separation techniques and cell-cycle analysis with dual-laser flow cytometry. Lymphocytes isolated from both involved and uninvolved lamina propria did not proliferate in response to LGV stimulation, whereas mitogen-induced proliferation was not different in lamina propria lymphocytes and the other lymphocyte populations. This lack of antigen-specific proliferation was not caused by a suppressor effect of mucosal T cells or monocytes or the absence of antigen-presenting cells. In contrast, lamina propria T lymphocytes from infected animals were able to provide antigen-specific help for polyclonal immunoglobulin synthesis by immune B lymphocytes after stimulation with LGV. Thus, in LGV proctitis in monkeys, mucosal antigen-reactive T cells differ from lymphocytes in other sites in that they can provide helper function, but are not able to proliferate in response to LGV antigens.

Cytotoxic and immunoregulatory function of intestinal lymphocytes in Chlamydia trachomatis proctitis of nonhuman primates

To study the role of natural killer cells and immunoregulatory T cells in the pathogenesis of proctitis due to Chlamydia trachomatis (L2 serovar), lymphocytes were obtained from the rectal mucosa and other sites of nonhuman primates and studied by using phenotypic and functional assays. In animals with lymphogranuloma venereum (LGV) proctitis, the percentage of lymphocytes with the natural killer cell phenotype (Leu-11+) was not significantly higher at any site in LGV infection, and natural killer cell function of lymphocytes isolated from the rectum was lower during LGV infection. This was not due to the suppressive effect of factors in serum, rectal lymphocytes, or LGV elementary bodies. In studies of regulatory T cells, the Leu-3+/Leu-2+ ratio was lower in the peripheral blood and the spleen during LGV infection, but the ratio did not decrease in lamina propria T cells. Both peripheral blood and rectal lymphocytes had higher helper T-cell function for polyclonal immunoglobulin G (IgG) synthesis in pokeweed mitogen-stimulated cultures 2 weeks following LGV infection. Increased suppressor T-cell function for pokeweed mitogen-stimulated IgG synthesis was found only in the peripheral blood of animals 2 weeks after infection, but not in isolated rectal lymphocytes. These results indicate that in LGV proctitis natural killer cells are not an important component of the inflammatory infiltrate at the site of infection, and helper T-cell function increases in peripheral blood and rectal lymphocytes.

Allergic proctitis and gastroenteritis in children. Clinical and mucosal biopsy features in 53 cases

We have reviewed 53 cases of allergic disorders of the gastrointestinal tract in children, including 15 with principal effects in the rectum (allergic proctitis) and 38 with dominant involvement of the upper and mid portions of the gut (allergic gastroenteritis). Most cases of allergic proctitis had their onset at less than 6 months of age, and all were under 2 years old when they presented with rectal bleeding alone or in combination with diarrhea. Rectal mucosal biopsy revealed in most cases a diffuse increase of eosinophils in the lamina propria together with a focal infiltration of the epithelium by eosinophils. Cases of allergic gastroenteritis affected all age groups and had a lower frequency of overt rectal bleeding. More common were other symptoms (vomiting, pain, and weight loss), an allergic history, anemia, blood eosinophilia, and increased serum IgE. Mucosal biopsy abnormalities were present in the gastric antrum in all cases sampled, the small intestine in 79%, the esophagus in 60%, and the gastric corpus in 52%. The lesions were usually diffuse and marked in the antrum and esophagus; in contrast, they tended to be focal and mild in the small intestine and gastric corpus. All cases of proctitis responded to a dietary change by cessation of symptoms without recurrences, whereas most of those with gastroenteritis had multiple relapses and required corticosteroid therapy.

Rectal mucosal plasma cells in inflammatory bowel disease

To achieve optimum staining and reproducible counts of plasma cells in paraffin embedded tissue with the immunoperoxidase technique we have found it essential to obtain a plateau count by titration of antisera for each specimen. This modification was used to study IgA, IgM, IgE, and IgG plasma cells in rectal biopsies from 20 controls, 20 patients with ulcerative proctocolitis, 20 with Crohn's colitis, 20 with non-specific proctitis, 15 with bacterial colitis, and seven with Crohn's disease but no apparent large bowel involvement. Counts were correlated with the characteristic histological features of inflammatory bowel disease. In controls the ratio of the mean counts for IgA, IgM, IgE, and IgG plasma cells was 8:3:3:1. All types of plasma cells were very significantly increased in the patients with ulcerative proctocolitis, Crohn's colitis, and non-specific proctitis and counts correlated with the severity of inflammation. There was no significant difference between the counts in these three groups. All counts tended to be higher in bacterial colitis than in controls, the difference being significant for IgA and IgE. When matched for severity of inflammation there was no significant difference between the counts in bacterial colitis and inflammatory bowel disease. The counts in patients with Crohn's disease but no large bowel involvement were not significantly different from controls. These results suggest that changes in plasma cell counts in inflammatory bowel disease are a non-specific response to mucosal damage, possible by a luminal irritant, and do not differentiate the type of inflammatory bowel disease.

Immunoglobulin E in non-specific proctitis and ulcerative colitis-studies with a monoclonal antibody

Reports of increased numbers of IgE-containing plasma cells in rectal biopsy specimens from patients with ulcerative colitis and non-specific proctitis have not been confirmed by others. All of these studies used conventional anti-IgE sera in immunocytochemical techniques and it is possible that the discrepancies are due to a lack of specificity of some of these reagents. A monoclonal antibody specific for human IgE was applied in this study of 23 patients. Positively stained cells were rarely found in the biopsy specimens of both the disease and normal control groups.

Allergic proctitis, a clinical and immunopathological entity

Patients with isolated ulcerative proctitis form a heterogeneous group. Some may develop ulcerative colitis, others have a limited, benign disease. Twelve patients with isolated proctitis with a mean course of seven years were studied. All patients had a typical clinical picture consisting of a mild and intermittent course of the disease with the presenting symptom of rectal blood loss. At endoscopic examination the inflammatory process was limited to the rectal and distal sigmoid colonic mucosa with a clear upper border beyond which the mucosa of the sigmoid colon was normal. Histologically the mucosal biopsy specimens of the affected rectum resembled those of ulcerative colitis. However, in contrast with proctitis on the base of ulcerative colitis or Crohn's disease, immunoperoxidase staining revealed a markedly increased number of IgE containing cells in the lamina propria of rectal mucosa biopsies. As an IgE-mediated immune mechanism was considered to play a role in this type of proctitis, eight of the 12 patients were treated with oral administration of disodium cromoglycate (DSCG). All patients were improved by the drug. The remaining four patients with mild proctitis did not require treatment. We concluded that, in patients with isolated proctitis on clinical and immunopathological criteria, a group can be separated which responds to DSCG, a condition for which we suggest the name 'allergic proctitis'.

Comparative analysis of systemic immunological parameters in ulcerative colitis and idiopathic proctitis: effects of sulfasalazine in vivo and in vitro

Comparative analysis of the systemic immunity revealed similarities between ulcerative colitis and idiopathic proctitis. In the active stage of both diseases, circulating complement receptor positive cells were increased whereas T-cell percentages and lymphocyte functions were decreased. In severe forms of ulcerative colitis and idiopathic proctitis circulating EAC-phagocytosing esterase positive cells, indicative of activated monocytes, were demonstrated. Successful treatment with salicylazosulfapyridine (SASP) reversed these immunological changes. Incubation of SASP and its metabolites with leucocytes from patients and control subjects, in concentrations similar to those demonstrated in sera from patients treated with SASP, did not alter the immunological changes.

Serum lysozyme, serum proteins, and immunoglobulin determinations in nonspecific inflammatory bowel disease

The serum levels of lysozyme, serum electrophoresis, and serum immunoglobulins were determined prospectively in 101 patients with ulcerative colitis, ulcerative proctitis, Crohn's disease, or nonclassifiable nonspecific inflammatory bowel disease. Although the mean serum lysozyme concentration of patients with Crohn's disease (10.5 +/- 6.8 microgram/ml) and ulcerative colitis (9.6 +/- 4.1 microgram/ml) performed by a standardized lysoplate method was significantly greater than normal controls (6.0 +/- 1.5 microgram/ml), the results did not correlate with the diagnosis nor with the degree of disease activity. Individually separated protein fractions and serum immunoglobulins also did not correlate with the serum lysozyme levels. This study indicates that measurement of the level of serum lysozyme in individual patients is not helpful in determining the cause or degree of activity of nonspecific inflammatory bowel disease.

Serial carcinoembryonic antigen (CEA) blood levels in patients with ulcerative colitis

Fifty-seven patients with ulcerative colitis were folloued 1-49 months (mean, 18 months) with serial CEA determinations during periods of remission, mild relapses, and severe relapses. Elevated CEA titers correlated with activity and possibly extent of disease: 12% of patients with proctitis, 47% of patients with left-sided colitis, and 60% of patients with transverse or universal colitis had elevated CEA titers during a flare. Moreover, 24% of patients with mild flares and 86% of patients with severe flares had elevated CEA titers. Ninety-two percent of patients with extensive disease and severe flares had elevated CEA titers. Elevated CEA titers were correlated with histologic findings in three patients. Inflammation of mucosa was demonstrated by colonoscopy and confirmed by biopsy in one patient with persistently elevated CEA titers during clinical remission. In two other patients with active disease whose CEA titers fell prior to colectomy, marked denudation of colonic mucosa was noted. In this study, a transiently elevated CEA titer indicated either clinically active ulcerative colitis or active inflammation of colonic mucosa.

Immunohistochemical changes in morphologically involved and uninvolved colonic mucosa of patients with idiopathic proctitis

Alterations in secretory component, IgA, IgG, and IgM were studied by immunofluorescent techniques in mucosal biopsy specimens obtained at colonoscopy from inflamed and grossly uninvolved colonic mucosa from 12 patients with idiopathic proctitis. Parotid-salivary secretory component and IgA and serum immunoglobulins were also investigated. Decreased secretory IgA was observed in the epithelium of all grossly involved rectal mucosa and in 40% of proximal normal mucosa. Salivary secretory IgA was not diminished. These observations suggest that a local immune defect may be pathogenetically related to idiopathic proctitis.

Immunoglobulin E in rectal mucosa of patients with proctitis

Rectal-biopsy specimens were obtained from a group of patients with proctitis in different stages of activity. Large numbers of brightly fluorescent IgE-producing cells were demonstrated in rectal-biopsy specimens taken from these patients during disease activity and clinical remission. An immediate hypersensitivity reaction is suggested as one of the mechanisms involved in the pathogenesis of proctitis.

The in-vitro action of lymphocytes on autologous colon epithelial cells in ulcerative colitis

The action in culture of peripheral blood lymphocytes on autologous large-intestinal epithelial cells was studied in 13 patients with severe mucosal ulcerative colitis. Two different methods were used to measure lymphocyte activity. These showed that autologous-lymphocyte-induced release of isotopic label and detachment in monolayer culture of large-intestinal epithelial cells was increased in acute ulcerative colitis when compared with findings in the same studies in six normal subjects. Subsequently in four of the six patients who responded to cortisone it was shown that lymphocyte activity against epithelial cells returned to the normal range. Further control studies showed little lymphocyte activity against autologous skin and ileum, suggesting that autologous-lymphocyte-induced damage of large-intestinal epithelial cells is a tissue-specific reaction in patients with acute ulcerative colitis. The absence of reactivity in other colonic inflammatory diseases also suggested that such increased in vitro lymphocyte activity is disease-specific for ulcerative colitis.

Carcinoembryonic antigen in patients suffering from ulcerative proctocolitis

Carcinoembryonic antigen (CEA) has been measured by radioimmunoassay in samples obtained from all patients suffering from ulcerative proctocolitis and seen within a four-month period. The characteristics of this group of patients have been compared with reported epidemiological studies in this disease, and have been found to have a similar sex ratio and age of onset, but a more limited disease. Among 59 patients, 11 were found to have elevated circulating CEA values. One of the 11 had a colonic carcinoma and another was pregnant. Excluding these two patients, an overall prevalence of elevated CEA levels of 17.5% was found. The prevelance in ulcerative proctitis was 7.1%, and in colitis was 19.9%. The patients in whom elelvated plasma CEA values were found were compared with the remaining patients in relation to factors known to be associated with an increased propensity for the development of colorectal carcinoma complicating ulcerative colitis. There was no difference in mean age of the patients at disease onset, nor was there any difference in disease duration, extent, and control. A significant correlation was found between elevated plasma CEA levels and the severity of the initial attack. One patient with premalignant changes in the rectal mucosa had consistently normal concentrations of plasma CEA. There was no significant correlation between elevated plasma CEA values and disease activity. The mean age of the two groups of patients was similar. No carcinoma has manifested in any patient during follow-up periods of at least 18 months.

Leucocyte migration inhibition with Kveim antigen in Crohn's disease

Forty-seven per cent of patients with Crohn's disease showed migration inhibition of their leucocytes in the presence of Kveim antigen. The incidence of positive tests bore no relationship to the severity of the disease or to corticosteroid therapy. Similar tests were consistently negative in twenty-four patients with idiopathic proctocolitis. The significance and diagnostic implications of these findings are discussed.